2017 Mississippi Code
Title 93 - Domestic Relations
Chapter 31 - Supporting and Strengthening Families Act
§ 93-31-5. Statutory form of power of attorney to delegate parental or legal authority

Statutory Form for Power of Attorney to

Delegate Parental or Legal

Custodian Powers

• 1. "I certify that I am the parent or legal custodian of:

  ____ ____

  (Full name of minor child) (Date of birth)

  ____ ____

  (Full name of minor child) (Date of birth)

  ____ ____

  (Full name of minor child) (Date of birth)

  who is/are minor children.

• 2. I designate____

  (Full name of attorney-in-fact)

  ____

  (Street address, city, state and zip code of attorney-in-fact)

  ____

  (Home phone, work phone and cell phone of attorney-in-fact)

  as the attorney-in-fact of each minor child named above.

• 3. [Complete either Section 3(a) or 3(b)].
  • (a) I delegate to the attorney-in-fact all of my power and authority

    regarding the care, custody and property of each minor child named above,

    including, but not limited to, the right to enroll the child in school,

    inspect and obtain copies of education records and other records concerning

    the child, the right to attend school activities and other functions

    concerning the child, and the right to give or withhold any consent or waiver

    with respect to school activities, medical and dental treatment, and any other

    activity, function or treatment that may concern the child. This delegation

    shall not include the power or authority to consent to marriage or adoption of

    the child, the performance or inducement of an abortion on or for the child,

    or the termination of parental rights to the child.

    OR

  • (b) I delegate to the attorney-in-fact the following specific powers

    and responsibilities (write in):

    ____

    [If Section 3(b) is completed, Section 3(a) does not apply.]

    This delegation shall not include the power or authority to consent

    to: marriage or adoption of the child, performing or inducing an abortion on

    or for the child, or the termination of parental rights to the child.

    [Complete either 4(a) or 4(b)]

• 4. (a) This power of attorney is effective for a period not to exceed

  one (1) year, beginning, ____, 20____, and ending ____, 20____. I reserve

  the right to revoke this authority at any time.

  OR

  [Complete either 4(a) or 4(b)]

  • (b) I am a serving parent as defined in Section 93-31-3, Mississippi

    Code of 1972. My active-duty service is scheduled to begin on ____, 20____,

    and is estimated to end on ____, 20____. I reserve the right to revoke this

    authority at any time. I acknowledge that in no event may this delegation of

    power last more than one (1) year or the term of my active duty plus thirty

By:____

(Parent/Legal Custodian signature)

• 5. I hereby accept my designation as attorney-in-fact for the minor

  child/children specified in this power of attorney.

  ____

  (Attorney-in-fact signature)

  State of ____

  County of ____

  ACKNOWLEDGEMENT

  Before me, the undersigned, a Notary Public, in and for said county and

  state on this ____ day of ____, 20____, personally appeared ____

  (Name of Parent/Legal Custodian) and ____ (Name of Attorney-in-fact),

  known to me to be the persons who executed this instrument and who

  acknowledged to me that each executed the same as his or her free and

  voluntary act and deed for the uses and purposes set forth in the instrument.

  Witness my hand and official seal the day and year above written.

  ____

  (Signature of notarial officer)

  (Seal, if any)

  ____

  (Title and Rank)

  My commission expires:____"

  • (2) A power of attorney that substantially conforms to the form set forth

    in this section is legally sufficient if the form is properly completed and

    acknowledged.